Chapter 28

Abdomen (2 of 9)
• Quadrant of bruising/pain can delineate
which organs are involved.
– RUQ
• Liver, gallbladder, duodenum, pancreas
– LUQ
• Stomach and spleen
– LLQ
• Descending colon, left half of transverse colon
– RLQ
• Large and small intestine, the appendix

Abdomen (3 of 9)
• RLQ is a common
location for
swelling and
inflammation.
• The appendix is a
source of infection
if it ruptures.

Abdomen (4 of 9)
• Hollow organs
– Stomach, intestines, ureters, bladder
– Structures through which materials pass
• Most of these contain digested food, urine, or
bile.

Abdomen (5 of 9)
• Hollow organs (cont’d)
– When ruptured or lacerated, contents spill into
peritoneal cavity.
• Can cause intense inflammatory reaction and
infection such as peritonitis

Abdomen (6 of 9)
• Hollow organs (cont’d)
– Small intestine
• Duodenum, jejunum, and ileum
– Large intestine
• Cecum, colon, and rectum
– Intestinal blood supply comes from mesentery.
• Mesentery connects the small intestine to the
posterior of the abdominal wall.

Abdomen (7 of 9)

Abdomen (8 of 9)
• Solid organs
– Liver, spleen, pancreas, kidneys
• Solid masses of tissue
• Perform chemical work of the body: enzyme
production, blood cleansing, energy
production
• Because of rich blood supply, hemorrhage
can be severe.

Abdomen (9 of 9)

Injuries to the Abdomen
• Injuries to the abdomen are considered
either open or closed.
– They can involve hollow and/or solid organs.

Closed Abdominal Injuries
(1 of 6)
• Blunt trauma to abdomen without breaking
the skin
– MOIs:
• Steering wheel
• Bicycle handlebars
• Motorcycle collisions
• Falls

(2 of 6)
• MOIs (cont’d):
– Compression
• Poorly placed
lap belt
• Being run over
by a vehicle
– Deceleration
• Fast-moving
vehicle strikes
an immoveable
object.

(3 of 6)
• Signs and symptoms
– Pain can be deceiving
• Often diffuse in nature
• May be referred to another body location
(such as the Kehr sign)
– Blood in peritoneal cavity produces acute pain
in entire abdomen.

(4 of 6)
• Signs and symptoms (cont’d)
– Difficult to determine location of pain.
• Guarding: stiffening of abdominal muscles
• Abdominal distention: result of free fluid,
blood, or organ contents spilling into
peritoneal cavity
• Abdominal bruising and discoloration
• May appear as abrasions initially

(5 of 6)
• Seatbelts
– Prevent many injuries and save lives.
• May cause blunt injuries of abdominal organs
– Particularly when belt lies too high
• Can cause bladder injuries to pregnant
patients
• Air bags
– Air bags are a great advancement.
• Must be used in combination with safety belts

(6 of 6)

Open Abdominal Injuries (1 of 6)
• Foreign object enters abdomen and opens
peritoneal cavity to outside.
– Also called penetrating injuries
– Examples: stab wounds, gunshot wounds
– Open wounds can be deceiving.
• Maintain a high index of suspicion.

• Injury depends on velocity of object.
– Low-velocity injuries
• Knives, other edged weapons
– Medium-velocity injuries
• Smaller caliber handguns and shotguns
– High-velocity injuries
• High-powered rifles and handguns

• High- and medium-velocity injuries
– Have temporary wound channels
– Caused by cavitation
• Cavity forms as pressure wave from projectile
transfers to tissues.
• Can produce large amounts of bleeding

• Low-velocity injuries
– Also have capacity to damage organs
– Internal injury may not be apparent.
– Injury at or below xiphoid process
• Assume it has affected the thoracic and
peritoneal cavities.

• Evisceration: bowel protrudes from
peritoneum.
– Can be painful and visually shocking
– Do not push down on abdomen.
– Only perform visual assessment.
– Cut clothing close to wound.
– Never pull on clothing stuck to or in the wound
channel.

• Signs and symptoms
– Pain
– Tachycardia
• Heart increases pumping action to
compensate for blood loss
– Later signs include:
• Evidence of shock
• Changes in mental status
• Distended abdomen

Hollow Organ Injuries (1 of 2)
• Often have delayed signs and symptoms
• Spill contents into abdomen
– Infection develops, which can take hours or
days.
– Stomach and intestines can leak highly toxic
and acidic liquids into peritoneal cavity.

Hollow Organ Injuries (2 of 2)
• Both blunt and penetrating trauma can
cause hollow organ injuries
– Blunt: causes organ to “pop”
– Penetrating: causes direct injury
• Gallbladder and urinary bladder
– Contents are damaging.
• Air in peritoneal cavity causes pain.
– Can cause ischemia and infarction

Solid Organ Injuries (1 of 5)
• Can bleed significantly and cause rapid
blood loss
– Can be hard to identify from physical exam
– Slowly ooze blood into peritoneal cavity

• Liver is the largest organ in abdomen.
– Vascular, can lead to hypoperfusion
• Often injured by fractured lower right rib or
penetrating trauma
• Kehr sign is common finding with injured
liver.

• Spleen and pancreas
– Vascular and prone to heavy bleeding
– Spleen is often injured.
• Motor vehicle collisions
• Steering wheel trauma
• Falls from heights
• Bicycle and motorcycle accidents involving
handlebars

• Diaphragm
– When penetrated or ruptured, loops of bowels
invade thoracic cavity.
• May cause bowel sounds during auscultation
of lungs
• Patient may exhibit dyspnea.

• Kidneys
– Can cause significant blood loss
– Common finding is blood in urine (hematuria).
– Blood visible on urinary meatus indicates
significant trauma to genitourinary system.

Patient Assessment of
Abdominal Injuries (1 of 2)
• Assessment of abdominal injuries is difficult.
– Causes of injury may be apparent, but resulting
tissue damage may not be.
– Patient may be overwhelmed with more painful
injuries.
– Some injuries develop and worsen over time,
making reassessment critical.

Patient Assessment of
• Patient assessment steps
– Scene size-up
– Primary assessment
– History taking
– Secondary assessment
– Reassessment

Scene Size-up (1 of 2)
• Scene Safety
– Information from dispatch may be sketchy or
vague.
– Standard precautions of gloves and eye
protection should be a minimum
– Be sure scene is safe for you
• If assault, domestic dispute, or drive-by
shooting is indicated, ensure police have
secured the area

• Mechanism of injury/nature of illness
– Observe the scene for early indicators of MOI
– Consider early spinal precautions
– If the wound is penetrating, inspect object of
penetration

Primary Assessment (1 of 5)
• Evaluate patient’s ABCs.
– Perform rapid scan.
• Helps establish seriousness of condition
– Some injuries will be obvious and graphic.
• Others will be subtle and go unnoticed.
– Injury may have occurred hours or days earlier.

• Form a general impression.
– Important indicators will alert you to seriousness
of condition.
– Don’t be distracted from looking for more
serious hidden injuries.
– Check for responsiveness using AVPU scale.

• Airway and breathing
– Ensure airway is clear and patent.
– Check for spinal injury.
– Clear airway of vomitus.
• Note the nature of the vomitus.
– A distended abdomen may prevent adequate
inhalation.
• Providing oxygen will help improve
oxygenation.

• Circulation
– Superficial abdominal injuries usually do not
produce significant external bleeding.
– Internal bleeding can be profound.
• Trauma to liver, kidneys, and spleen can
cause significant internal bleeding.
• Evaluate pulse, skin color, temperature, and
condition to determine stage of shock.
• Treat aggressively.

• Transport decision
– Abdominal injuries generally indicate a quick
transport to the hospital.
• Delay in medical evaluation may result in
unnecessary and dangerous progression of
shock.
• Patients with abdominal injuries should be
evaluated at the highest level of trauma
center available.

History Taking (1 of 2)
• Investigate chief complaint.
– Further investigate MOI.
– Identify signs, symptoms, and pertinent
negatives.
– Movement of body or abdominal organs irritates
peritoneum, causing pain.
• To minimize this pain, patients will lie still with
knees drawn up.

• SAMPLE history
– Use OPQRST to help explain injury.
– If patient is not responsive, obtain history from
family or friends.
– Ask if there is nausea, vomiting, or diarrhea.
– Ask about appearance of any bowel movements
and urinary output.

Secondary Assessment (1 of 6)
• May not have time to perform in field
• Physical examinations
– Inspect for bleeding.
– Remove or loosen clothes to expose injuries.
• Provide privacy.
– Patient should remain in position of comfort.
• Relieves tension

• Physical examinations (cont’d)
– Examine entire abdomen.
• Critical step for patients with entrance wound
– Evaluate the bowel sounds.
• Can be difficult to hear
• Hypoactive = cannot hear sounds
• Hyperactive = lots of gurgling and gas
moving about

– Use DCAP-BTLS.
• Inspect and palpate for deformities.
• Look for presence of contusions, abrasions,
puncture wounds, penetrating injuries, burns.
• Palpate for tenderness and attempt to
localize to specific quadrant of abdomen.
• Swelling may indicate significant intra-
abdominal injury.

– Palpate farthest away from quadrant exhibiting
signs of injury and pain.
• Allows you to investigate possibility of
radiation of pain
– Perform full-body scan to identify injuries.
• Begin with head and finish with lower
extremities.
• If you find life threat, stop and treat it.

– If MOI suggests isolated injury, focus physical
exam on injured area.
• Inspect for entrance and exit wounds.
• Do not remove impaled objects.
– Inspect and palpate kidney area for tenderness,
bruising, swelling, or other trauma signs.
• Hollow organs will spill contents into
peritoneal cavity.

• Vital signs
– Many abdominal emergencies can cause a
rapid pulse and low blood pressure.
– Record of vital signs will help identify changes
in condition.
– Use appropriate monitoring devices.

Reassessment (1 of 3)
• Repeat the primary assessment and
reassess vital signs.
– Reassess interventions and treatment.
• Interventions
– Manage airway and breathing problems.
– Provide spinal stabilization.
– Treatment for shock
– Cover wounds

• Communication and documentation
– Communicate all relevant information to staff at
receiving hospital.
– Use appropriate medical and anatomic
terminology.
• When in doubt, describe what you see.
– Document results of physical exam and
pertinent negatives.
• Also document any steps that were skipped.

• Communication and documentation (cont’d)
– Describe scene in enough detail to give trauma
team a clear understanding.
– Be cautious and diligent when dealing with
patients who refuse transport.
• These patients are at high risk for
complications.

Emergency Medical Care of
• Closed abdominal injuries
– Biggest concern is not knowing the extent of
injury.
• Patient requires expedient transport.
– Primarily to trauma center with surgeon
• Position for comfort
• Apply high-flow oxygen.
• Treat for shock.

• Closed abdominal injuries (cont’d)
– Patient with blunt abdominal wounds may have:
• Severe bruising of abdominal wall
• Liver and spleen laceration
• Rupture of intestine
• Tears in mesentery
• Rupture of kidneys or avulsion of kidneys

• Closed abdominal injuries (cont’d)
– Patient with blunt abdominal injury should be
log rolled to a supine position on a backboard.
– Protect the spine.
– Monitor vital signs.

• Open abdominal injuries
– Patients with penetrating injuries
• Generally obvious wounds, external bleeding
• High index of suspicion for serious unseen
blood loss
• Surgeon will assess damage.

• Open abdominal injuries (cont’d)
– Inspect patient’s back and sides for exit wound.
– Apply dry, sterile dressing to all open wounds.
– If penetrating object is still in place, apply
stabilizing bandage around it.

• Open abdominal
injuries (cont’d)
– Evisceration
• Severe
lacerations of
abdominal wall
may result in
internal organs
or fat protruding
through wound.

• Open abdominal injuries (cont’d)
– Never try to replace a protruding organ.
• Keep the organs moist and warm.
• Cover with moistened, sterile gauze or
occlusive dressing.
• Secure dressing with bandage.
• Secure bandage with tape.

Anatomy of the Genitourinary
System (1 of 3)
• Controls reproductive functions and waste
discharge
– Generally considered together
– Male genitalia lie outside pelvic cavity.
• Except prostate gland and seminal vesicles
– Female genitalia lie within pelvic cavity.
• Except vulva, clitoris, labia

System (2 of 3)

System (3 of 3)

Injuries of the Genitourinary
System (1 of 8)
• Kidney injuries
– Rarely seen but not unusual
– Kidneys lie in well-protected area.
• Forceful blow or penetrating injury often
involved

System (2 of 8)
• Suspect kidney damage if patient has a
history or physical evidence of any of the
following:
• Abrasion, laceration, contusion in the flank
• Penetrating wound in region of flank or upper
abdomen
• Fractures on either side of lower rib cage or
of lower thoracic or upper lumbar vertebrae
• A hematoma in the flank region

System (3 of 8)

System (4 of 8)
• Urinary bladder injuries
– May result in rupture
• Urine spills into surrounding tissues.
• Blunt injuries to lower abdomen or pelvis can
rupture urinary bladder.
– In males, sudden deceleration can shear the
bladder from the urethra.
– In later trimesters of pregnancy, bladder injuries
increase.

System (5 of 8)

System (6 of 8)
• External male genitalia injuries
– Soft-tissue wounds
– Painful and of great concern for patient
• Rarely life threatening
• Should not be given priority over more severe
wounds

System (7 of 8)
• Female genitalia injuries
– Internal female genitalia
• Uterus, ovaries, fallopian tubes are rarely
damaged.
• Exception is pregnant uterus
– Uterus enlarges substantially and rises out of
pelvis
– Injuries can be serious.
– Also keep fetus in mind.
– In last trimester of pregnancy, uterus is large and
may obstruct vena cava.

System (8 of 8)
• Female genitalia injuries (cont’d)
– External female genitalia
• Vulva, clitoris, major and minor labia
• Very rich nerve supply
• Consider sexual assault and pregnancy.
• If there is external bleeding, a sterile
absorbent sanitary pad may be applied to the
labia.
• Do not insert anything into the vagina.

Patient Assessment of the
Genitourinary System (1 of 2)
• Potential for patient embarrassment
– Maintain a professional presence.
– Provide privacy .
– Have EMT of same gender perform
assessment.
– Look for blood on patient’s undergarments.

Patient Assessment of the
Genitourinary System (2 of 2)
• Patient assessment steps
– Scene size-up
– Primary assessment
– History taking
– Secondary assessment
– Reassessment

• Scene safety
– Assess the scene for hazards and threats.
– Assess the impact of hazards on care.
– Assess for the potential for violence and
environmental hazards.
– At minimum, gloves and eye protection are
required.

• Mechanism of injury/nature of illness
– Look for indicators of MOI.
• Consider how MOI produced the injuries
expected.
• Patient may avoid the discussion to avoid
undergoing a physical exam.
• Patient may also provide an MOI that seems
less embarrassing than the actual MOI.

• Quickly scan patient to identify any treat life
threats.
– Genitourinary system is very vascular.
• Injuries can produce significant volume of
blood.
– Do not avoid this area in the rapid scan.
• If bleeding is present, inspect exterior
genitals for visible injury.

• Form a general impression.
– Important indicators will alert you to the
seriousness of the condition.
• Is the patient awake and interacting?
• Are there any life threats?
• What color is the patient’s skin?
• Is he or she responding appropriately or
inappropriately?

• Airway and breathing
– Ensure the patient has a clear and patent
airway.
• Protect from further spinal injury.
– Consider advanced airway if patient is
unresponsive.
• Circulation
– Genitourinary system can be a significant
source of bleeding.

• Circulation (cont’d)
– Assess pulse rate and quality.
– Determine skin condition, color, and temp.
– Check capillary refill time.
• Closed injuries do not have visible signs of
bleeding.
• Control bleeding if seen.

• Transport decision
– Any injury to the genitourinary system can be
life altering.
• Often, injuries require medical specialist for
specialized care.

• Investigate chief complaint.
– Determine why 9-1-1 was called.
– Common associated complaints with
genitourinary injuries are:
• Nausea and vomiting
• Diarrhea
• Blood in urine
• Vomiting blood
• Abnormal bowel and bladder habits

• SAMPLE history
– Use OPQRST to learn about patient’s pain.
– Ask patient about output.
• Especially urine in blood
– Ask about allergies.
– The importance of past medical history cannot
be overstated.
– Ask when was last intake of food and fluid.
– Address events leading up to injury.

• Physical examinations
– Genitourinary system injuries can be awkward
to assess and treat.
• Privacy is a genuine concern.
– Focus on specific region of body when isolated
injury is present.
– Look for DCAP-BTLS.
– Identify wounds and control bleeding.

– Start with a full-body scan for significant trauma.
• Presence of penetrating injury indicates
possible internal injury.
• Presence of burns must be noted and
managed immediately.
• Palpate for tenderness to localize the injury
and presence of fractures.
• Look for lacerations and local swelling.

• Vital signs
– Obtain the patient’s vital signs
• Important to reassess vital signs to identify
differences in condition.
• Tachycardia; tachypnea; low blood pressure;
weak pulse; and cool, moist, pale skin
indicate hypoperfusion.
• Use pulse oximetry and noninvasive blood
pressure devices when available.

Reassessment
• Interventions
– Provide oxygen and maintain airway.
– Control bleeding and treat for shock.
– Place patient in position of comfort and
transport.
• Communication and documentation
– Communicate all concerns to hospital staff.
– Describe and document all injuries and
treatments given.

Genitourinary Injuries (1 of 12)
• Kidney injuries
– Injuries may not be obvious.
• However, you will see:
– Signs of shock
– Blood in urine (hematuria)
– Treat for shock, transport promptly, monitor vital
signs en route.

• Urinary bladder injury
– Suspect if you see:
• Blood at urethral opening
• Signs of trauma to lower abdomen, pelvis,
perineum
– In presence of shock or associated injuries:
• Transport promptly.
• Monitor vital signs en route.

• External male genitalia
– General rules for treatment:
• Make patient comfortable.
• Use sterile, moist compresses to cover areas
stripped of skin.
• Apply direct pressure with dry, sterile gauze
dressings to control bleeding.
• Never move or manipulate foreign objects in
urethra.

• External male genitalia (cont’d)
– General rules for treatment (cont’d):
• Identify and take avulsed parts in bag to
hospital with patient.
– Amputation of penile shaft
• Managing blood loss is top priority.
– Use local pressure with sterile dressing.

– If connective tissue surrounding erectile tissue
is damaged, shaft can be fractured or angled.
• Sometimes requires surgical repair
• Injury may occur during active sexual
intercourse.
• Associated with intense pain, bleeding, and
fear

– Laceration of head of penis
• Associated with heavy bleeding
• Apply local pressure with sterile dressing.
– Skin of shaft or foreskin caught in zipper
• If small segment of zipper is involved, try to
unzip.
• If long segment of zipper is involved, cut the
zipper out of the pants with heavy scissors.

– Urethral injuries are not uncommon
• Straddle injuries, pelvic fractures, and
penetrating wounds of the perineum
• Important to know if patient can urinate and if
there is blood in urine
– Save urine for hospital examination.
• Foreign bodies protruding from urethra will
have to be surgically removed.

– Avulsion of the skin of the scrotum may damage
scrotal contents.
• Preserve avulsed skin in a moist sterile
dressing.
• Wrap scrotal contents or perineal area with a
sterile moist compress; use local pressure for
bleeding.
– Direct blows to scrotum can result in rupture of a
testicle or accumulation of blood around testes.
• Apply ice to scrotal area.

• Female genitalia
– Treat lacerations and avulsions with moist,
sterile compresses.
• Use local pressure to control bleeding.
• Hold dressings in place with diaper-type
bandage.
– Do not pack dressings into vagina.

• Female genitalia (cont’d)
– Leave any foreign bodies in place after
stabilizing with bandages.
– Injuries are painful but not life threatening.
• In-hospital evaluation required.
• Transport urgency determined by associated
injuries, amount of hemorrhage, presence of
shock.

• Rectal bleeding
– Common complaint
• May present as blood in or soaking through
undergarments
– Possible causes include sexual assault,
hemorrhoids, colitis, ulcers.
• Rectal bleeding possible after hemorrhoid
surgery

• Rectal bleeding (cont’d)
– Acute rectal bleeding should never be passed
off as something minor.
• Pack crease between buttocks with
compresses.
• Consult medical control to determine need for
transport.

Sexual Assault (1 of 4)
• Sexual assault and rape are common.
• Victims are generally women.
– Sometimes men and children
– Often little you can do beyond providing
compassion and transport.
– Patient may have sustained multisystem
trauma.
• Will need treatment for shock.

• Do not examine genitalia unless obvious
bleeding requires application of dressing.
• Follow appropriate procedures and
protocol.
– Shield patient from curious onlookers.
– Document patient’s history, assessment,
treatment, and response to treatment.

• Follow crime scene policy of your EMS
system.
– Advise patient not to wash, douche, urinate, or
defecate until after examination.
– If oral penetration occurred, advise patient not
to eat, drink, brush the teeth, or use mouthwash
until after examination.
– Handle patient’s clothes as little as possible.

• Make sure EMT caring for patient is same
gender as patient whenever possible.
• Treat medical injuries and provide privacy,
support, reassurance.

Chapter 28

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